Patient Questionnaire

About You
Title*
Name*
Forename(s) Surname
Previous Surname
Date of Birth*

Day
Month
Year
Occupation
Address*
Street Address Address Line 2 City County Post code Country
Email*
Phone Number*
Secondary Phone Number

Personal History
Smoking
Do you smoke?*
- Yes
- No
Have you ever smoked?*
- Yes
- No
If you're an ex-smoker when did you stop (approx month and year) and how much did you smoke before giving up?
If you are a current smoker…
What do you smoke?
- Cigarettes
- Cigars
- Pipe
How much do you currently smoke?

(cigarettes/day or grams tobacco/week)
Would you like help to smoking?
- Yes
- No
If you are a smoker and you wish to have help stop smoking, please make an appointment with one of our smoking advisors for help and advice.

Alcohol

Alcohol use can affect your health and can interfere with certain medications and treatments. Your answers will remain confidential so please be honest.Use the guide below to decide how many units you drink a week.

Pint of regular beer / lager / cider	2 units
Alcopop or can of lager	1.5 units
Glass of wine (175ml)	2 units
Single measure of spirits	1 units
Bottle of wine	9 units

How many units of alcohol do you consume in an average week?*
Answer the following questions and then add up the points for each answer at the end
How often do you have a drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
Your total score*

A total of 5+ indicates increasing or higher risk drinking. If your score is 5+ you may be asked to fill in a further questionnaire.

Step 1 of 4

About You

Your Height and Weight

Your Ethnic Group

Personal History

Smoking

If you are a current smoker…

Alcohol

Family history

Cares and the cared for

Does someone care for you?